A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?

Sends the incident report to the ethics committee

Lists names of witnesses to the fall in the nurses' notes

Includes the client's account of the fall in the incident report

Documents in the client's record that an incident report was filed

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not an appropriate action by the staff nurse. The incident report should not be sent to the ethics committee, as it is not a part of the client's record and does not involve ethical issues. The incident report should be sent to the risk management department, which is responsible for identifying and preventing potential hazards and liabilities in the health care setting.

Choice B reason: This is not an appropriate action by the staff nurse. The names of witnesses to the fall should not be listed in the nurses' notes, as they are not relevant to the client's care and may violate confidentiality. The names of witnesses should be included in the incident report, which is a confidential document that is not part of the client's record.

Choice C reason: This is an appropriate action by the staff nurse. The client's account of the fall should be included in the incident report, as it provides valuable information about the circumstances and causes of the fall. The incident report should also include the date, time, location, and description of the fall, the staff members involved, the interventions taken, and the client's condition and response.

Choice D reason: This is not an appropriate action by the staff nurse. The fact that an incident report was filed should not be documented in the client's record, as it may imply negligence or fault and may be used as evidence in a legal case. The incident report is a separate document that is used for quality improvement and risk management purposes.

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Correct Answer is D

Explanation

Choice A reason: This is not the correct choice because witnessing the client signing the consent form is not a valid option. The client is a minor and cannot legally consent to their own treatment without the permission of their guardian, unless they are emancipated, married, or pregnant.

Choice B reason: This is not the correct choice because asking the adult neighbor to sign the consent form is not a valid option. The adult neighbor is not a legal guardian or a close relative of the client and has no authority to consent to the client's treatment.

Choice C reason: This is not the correct choice because obtaining consent from the hospital administrator is not a valid option. The hospital administrator is not a medical professional or a legal representative of the client and has no authority to consent to the client's treatment.

Choice D reason: This is the correct choice because attempting to notify the client's guardian to obtain consent is the best option. The client's guardian is the person who has the legal right and responsibility to make decisions for the client's health care. The nurse should try to contact the guardian by phone or other means and obtain verbal or written consent for the emergency surgery. If the guardian cannot be reached, the nurse should follow the facility's policy and procedure for obtaining consent in emergency situations.

A. "Please ask your relative about this, because I cannot share information about her." B. "I'm not taking care of your relative today, so I don't have the latest information." C. "I will have your relative's nurse come and talk with you about her care." D. "Let me check your relative's medical record to see how she's doing."

Correct Answer is C

Explanation

Choice A reason: This response is inappropriate because it violates the client's right to privacy and confidentiality. The nurse should not disclose any information about the client to anyone without the client's consent, unless it is required by law or for the client's safety.

Choice B reason: This response is inappropriate because it shows a lack of accountability and professionalism. The nurse should not dismiss the visitor's concern or pass the responsibility to another nurse. The nurse should either provide the information if they have it or direct the visitor to the appropriate source.

Choice C reason: This response is appropriate because it respects the client's privacy and confidentiality, while also addressing the visitor's concern. The nurse should inform the visitor that they will contact the nurse who is taking care of the client and ask them to come and talk with the visitor.

Choice D reason: This response is inappropriate because it violates the client's privacy and confidentiality. The nurse should not access the client's medical record without a valid reason or the client's consent. The nurse should only check the medical record if they are involved in the client's care or have a need to know the information.

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A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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